Case Discussion R1 吳宗祐 R4 呂筱涵 VS 楊燿榮 2017/05/03 Nelson 1812 (2620)

Patient Profile Name: 張X妍 Chart number: 181675xx Age: 2-year-old Gender: Female Date of admission: 2017/04/22~04/26 Informant: Parents and medical records

Chief Complaints Abdominal pain since 4 days ago

Present Illness 2017/04/18 Intermittent pain Inconsolable crying and bend-over position during pain Returned to usual activity and appetite when the pain ended No fever, no diarrhea, no vomiting, no bloody stool No fever/URI/UTI/AGE in recent 2 weeks Constipation: denied

Past History Birth Hx: Growth and development: Vaccination: G2P2, GA 34-35wks, NSD, BBW: 2640g Uneventful perinatal hx Growth and development: BL: 83 cm = 3-15th percentile BW: 10.6 kg = 15-50th percentile Developmental milestone: within normal limits Vaccination: As Taiwan schedule, Rotavirus: (+). Influenza (2016): (-) Contact history: denied Family history Older brother had 2 episodes of intussusception (2 years old and 3 years old, s/p Barium enema reduction)

PE Vital Signs: T: 36.0°C(04/22 20:20); P: 118/min(04/22 20:20) R: 24/min(04/22 20:20); BP: 124/75mmHg(04/22 20:20) Consciousness: clear, General appearance: fair HEENT: conjunctiva: not pale, sclera: anicteric Neck: supple, no JVE, no LAP Chest: symmetric expansion, bilateral clear breath sounds Heart: regular heart beat, murmur(-) Abdomen: flat and soft, normo-active bowel sound, tenderness (- ), rebound pain (-), palpable mass (-) Extremities: warm, pitting edema (-) Skin: no edema, petechiae or ecchymosis

Lab

Impression Intussusception Constipation Pancreatitis Herniation Acute abdomen The patient was brought to 奇美H on 2017/04/19

Image 04/19 19:24 灌 灌

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Image 04/20 13:05 再灌 再灌

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Image 04/22 02:06 灌 灌 灌 灌 灌 灌 灌 灌

Treatment course 2017/04/19 @ 奇美H Intussusception Repeated Barium reduction up to 4 times due to recurrence 04/19 19:24 04/20 13:05 04/21 10:52 04/22 02:06 Transferred to our emergency department on 2017/4/22

Treatment course 2017/04/22 @ NCKUH ER Initial vital signs: T/P/R 37.2/108/20 Abdominal sonography Target lesion at RUQ of abdomen without significant bowel swelling or local fluid accumulation Multiple enlarged lymph nodes Recurrent intussusception and mesenteric lymphadenitis were favored May try Barium reduction again

Image 04/22 13:32

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Treatment course 2017/04/22 @ NCKUH ER Steroid + IV hydration Hydrocortisone 20mg IVD STAT (2mg/kg/dose) 5th Barium reduction  FAILED Surgery at 04/22 18:05 Ileocolic type intussusception about 2 cm Manual reduction Ileum congestion, hyperemia thickened about 15 cm Appendectomy Mesenteric side with enlarged multiple LN up to 1 cm biopsy and sent for pathology and viral isolation

Final Diagnosis Intussusception, status post barium reduction, status post surgical manual reduction on 2017/04/22

Discussion – Intussusception Most common cause of intestinal obstruction between 5m/o to 3y/o Most common abd emergency in < 2y/o 90% idiopathic Seasonal incidence peaks in fall and winter Respiratory adenovirus (type C) Slightly increased risk after receiving rotavirus vaccine

Discussion – Intussusception 2~8% of cases has a recognizable leading point

Discussion – Intussusception Clinical manifestations Sudden onset, severe paroxysmal colicky pain, recurs frequently Straining efforts, legs/knees flexed Loud crying Plays normally between the episodes Vomiting  vomit with bile content Currant jelly stool (only 60% of cases) Sausage-shaped abdominal mass (most often at RUQ) Recurrent intussusception: 5~8% Classic triad (<30%)

Discussion – Intussusception Diagnosis Ultrasound: A tubular mass in longitudinal views, a doughnut or target sign in transverse views Air, hydrostatic (saline), water-soluble contrast enema Contrast (Barium) enema Treatment Hydrostatic reduction 80-95% successful rate in ileocolic type Bowel perforation rate: 0.5-2.5% Air reduction Perforation rate: 0.1-0.2% Surgical intervention Multiple recurrences Bowel necrosis, perforation, peritonitis… Ileoileal type

Discussion – Intussusception Prognosis Recurrence rate (most within 72hrs) Reduction: 10% Surgical reduction: 2-5% Surgical resection: none Corticosteroid Reduce the frequency of recurrence Multiple recurrences Suspect a leading point Consider exploratory laparotomy

REVIEW Intussusception v.s. Steroids

Review I

Review I -- Abstract 2 cases of recurrent intussusception associated with intestinal lymphoid hyperplasia (ILH) A short course of steroids Resolution of symptoms and hyperplasia Steroids before surgical approach Recurrent intussusception in association with ILH No other lead point can be identified

Review I -- Case 1 10 m/o female with intussusception 2 previous episodes at 7m/o and 8m/o No identifiable lead point Negative Meckel’s scan Upper GI series & Double-contrast barium enema: multiple small, round filling defects along the distal small bowel and colon

Oral prednisone 1mg/kg/day for 2 weeks, and gradual tapering for 4 weeks F/u double-contrast barium enema after 2 months No recurrence during 2-year follow up Before After

Review I -- Case 2 5y/o male with intussusception 2 previous episode at 1.5y/o and 4y/o No identifiable lead point Negative Meckle diverticulum scan Upper GI series: ILH in terminal ileum and cecum Suspect recurrence 12hrs after air reduction

Oral prednisone 1mg/kg/day for 2 weeks, and gradual tapering for 4 weeks No recurrence during 18-month follow up

Review I -- Conclusion Steroids before surgical approach or repeat pneumatic or hydrostatic reduction Recurrent intussusception in association with ILH No other lead point can be identified

Review II Decreasing early recurrence rate of acute intussusception by the use of dexamethasone Eur J Pediatr. 2000 Jul;159(7):551-2 Lin SL, Kong MS, Houng DS. Prospective, randomized, double-blinded study Pretreated with dexamethasone (0.5mg/kg) before pneumoreduction

Review II -- Method Steroid group Normal saline group 122 successful reduction (84.7%) No recurrence during 72hrs admission No recurrence during 1st week 1 recurrence in 6 months No mortality, nor bowel perforation Normal saline group 117 successful reduction (85.4%) 3 (2.5%) recurrence during 72hrs admission 6 (5.1%) episodes of recurrence during 1st week (P<0.05) 8 (6.8%) recurrence in 6 months

Review II -- Conclusion Amelioration of lymphoid hyperplasia by dexamethasone may be the main mechanism in reducing the recurrence rate of acute intussusception

Review III

Review III -- Case report 11m/o boy with 3-day abdominal pain, blood and mucus stool  intussusception  gas reduction In the subsequent 4 months, 9 episodes of recurrence After the 5th recurrence, diagnostic laparoscopy was performed Moderate mesenteric lymphadenopathy Ileo-caecal valve scarring After the 8th recurrence, oral prednisone (10mg QD) for 2 weeks, and then tapering down in 6 weeks. No recurrence since then.

Review IV

Review IV -- Method Aged from 1 week to 18 years, from 1999 to 2014 Idiopathic intussusception, exclusion criteria: Known underlying intestinal pathology Underwent surgical intervention Steroid administration No randomization Decision made by the attending pediatric surgeon Complete pneumatic reduction Group 1: IV dexamethasone (0.5mg/kg/dose) on diagnosis of immediately after reduction Group 2: No steroids Early recurrence Within 1 week of successful reduction

Review IV -- Results & Discussion Total 174 patients (113M + 61F) 100 steroid: 14 with early recurrence (14%) 74 non-steroid: 4 with early recurrence (5%) P=0.08 Discussion Most of the intussusception were idiopathic This study do not justify the routine use of steroid Steroid may have a role in lymphoid hyperplasia

Thank you for your attention